High Tibial Osteotomy

1. High Tibial Osteotomy Planning and Indications

2. 45yo female • Active lifestyle • Not overweight

3. 12 weeks

4. Goals of Treatment • Pain Relief • Maintain or Improve function • Stay in the work force • Sport

5. Non – Operative Treatment • Lifestyle Modification • Weight loss • Low impact • Change occupation • Change sport

6. Non – Operative Treatment • Paracetamol • NSAIDs • significant reduction in pain compared to placebo • GIT risks • Glucosamine / Chondroitin Sulfate • Cochrane review = no definitive clinical benefit vs placebo • Steroid Injection • Effective short term • Viscosupplementation • Cochrane review no benefit over placebo

7. Non – Operative Treatment • Physiotherapy • Relationship / painful treatment • Quads strengthening • Stretching

8. Non – Operative Treatment • Bracing and heel wedges • Some effect • Daily use? • 2 years - 25% compliance

9. Operative Treatment Options • Needle Lavage • Not significant benefit • Arthroscopic Debridement • Reserved for mechanical symptoms

10. Operative Treatment Options • UKA • Good patient satisfaction • Physiologic function • Accelerated rehab and recovery time • Discharge day 1-3 • Conversion to TKR improving • Double the revision rate compared to TKR • labour • Bone stock

11. TKR

12. TKR

13. Operative Treatment Options • HTO • Morrey JBJS 1989 • 34 osteotomies • 7.5 yr fu • 73% satisfactory results • Bourne 1999 • 106 Osteotomies • Survivorship 5yrs = 73%, 10yrs = 51% • In patient <50 5yrs = 95%, 10yrs = 80% • Hui Am J Sports Med 2010 • 349 osteotomies • Mean fu 12 years (1-19yrs), avg age 50yrs • Survival 5yrs = 95%, 10yrs = 79%, 15yrs = 56% • 10yrs = 21% failure rate (reoperation) • Results for conversion HTO to Primary TKR not different to primary OA to TKR • Results UKR to TKR slightly better than a TKR to revision TKR

14. Operative Treatment Options • HTO downside • General risks • Non-union • Fracture • Painful • Long rehab • Pain not all gone • Arthroplasty in the future

15. Lateral Closing Wedge

16. Medial Opening Wedge 12 weeks

17. Indications • Genu Varum with medial OA • Adult OCD • Osteonecrosis • PLC instability

18. Appropriate Patient • Young patient (<60 relative) • Active • Motivated for rehabilitation • BMI <30 (<1.32x ideal bw)

19. Appropriate Joint • Unicompartmental pathology • Correlation with XRs • Non Inflammatory • FFD <15degrees • Flexion arc >90 degrees • Varus <15 degrees, Valgus <12 degrees

20. Contraindications • Smokers • Lateral compartment OA or previous injury / menesectomy • Inconsistent pain • Inflammatory arthritis • Obese (BMI >30) • FFD >15 degrees

21. Pre – op Planning • Correct patient • Deformity • Tibial • Femoral • Both • Axes • Mechanical • Anatomical • Correction desired • Implant choice • Graft type

22. Pre – op Planning - Deformity • Standing Long leg views • MRI to check other compartments

23. Pre – op Planning - Deformity mLDFA = 88o mPTA = 81o

24. Pre – op Planning - Axis • Mechanical Axis • Femoral – Tibial • 2o varus med 75%, lat 25% • 0o (centre) med 60% lat 40% • 4o valgus med 50% lat 50% • 6o valgus med 40% lat 60% • Correction angle • Angle of deformity + 4-6o = 14o 8o mLDFA = 88o mPTA = 81o

25. Pre – op Planning – Fujisawa point • Simplify • 14 degrees 14o

26. Pre – op Planning – Correction • Now we know the angle of correction - ? • mm opening • First 10mm : 1mm = 1o correction • Variation in tibial length and metaphyseal width • 14mm < 14o • C- arm II • Navigation

27. Pre – op Planning – Correction • Now we know the angle of correction - ? • mm opening • First 10mm : 1mm = 1o correction • Variation in tibial length and metaphyseal width • 14mm < 14o

28. Fixation • Spacer plate • Rigid locked plates

29. Bone Graft • Opening wedge • Structural support • Biological healing • Scaffold • Autograft vs Allograft vs Synthetic substitute • No need?

30. Steps 1 2 3

32. Summary • Correct patient • Locate the deformity for correction • Axes • Correction • Implant • Graft